Functional Dyspepsia: Tips to Help Patients Feel Better

An expert on this common disorder of gut-brain interaction shares her symptom relief recommendations with the Curbsiders.
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-- TRANSCRIPT --
Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Frank Watto, here with my great friend, Dr Paul Nelson Williams. We are about to talk about functional dyspepsia, which is a disorder of gut-brain interaction. Paul is America's primary care physician, so we're lucky to have him to help guide us through this.
We discussed functional gastrointestinal disorders with expert Dr Iris Wang, who reminded us that the central nervous system and the enteric nervous system develop as one embryologically, and then they separate. That's part of why neuromodulators work on the gut. When she's talking to patients about irritable bowel syndrome or functional dyspepsia, she says, "I think this is what you have. I expect the testing to be negative. We just don't have good tests to diagnose these conditions. That doesn't mean this is all in your head. And I have some treatments that can help you."
Paul N. Williams, MD: She frames it very much as a positive diagnosis. We typically think of these conditions as diagnoses of exclusion. But often we are fairly certain what we are dealing with, and we can communicate that to the patient up front. That's such a helpful way to frame it rather than "this is what's left after I rule out all the scary stuff," which is probably not doing the patient a service.
Watto: For functional dyspepsia, what is the basic testing? The patient is coming in with epigastric abdominal pain. What basic testing should we think about getting?
Williams: Just a quick reminder. There are two types: postprandial distress and epigastric pain syndrome. They are exactly what they sound like.
Even though I just said that you can be fairly certain what you're dealing with before you actually do any testing, your due diligence probably should include Helicobacter pylori testing. That's part of the guidelines, and although the evidence that treating H pylori will fix the symptoms isn't super-strong, it's still a good thing to do.
The other thing that's recommended is to treat these patients empirically with a trial of a proton pump inhibitor at an appropriate dose, for at least 4 weeks. Dr Wang also mentioned that, interestingly, the H2 receptor antagonists also seem to help decrease gut hypersensitivity. These syndromes seem to have a lot of visceral hypersensitivity, and the H2 blockers may mitigate that somewhat, which I thought was really interesting.
Watto: Are you recommending caraway tea to your patients, Paul? Dr Wang mentioned that caraway seeds could be steeped in tea and can help.
Williams: No, I like it when my patients come back to see me, so I've held off on that particular recommendation because it sounds absolutely disgusting.
Watto: But there is a branded over-the-counter product that has caraway oil and menthol in it that your patients can try. Dr Wang said patients can also try peppermint oil; however, if the patient has gastroesophageal reflux disease, it can relax the lower esophageal sphincter, so you should avoid peppermint in that case.
Williams: She also made the very reasonable point that this is not the essential oil that you're putting in a diffuser. Don't take that oil by mouth because it will poison you, which is why a marketed pharmaceutical product is what you're looking for here. She said that peppermint tea might work if your patient is not wildly excited about taking peppermint oil supplements.
Watto: Postprandial distress syndrome is what it sounds like. These patients have a little bit of a problem with accommodation of the stomach. One of the neuromodulators that she talked about using for postprandial distress syndrome is buspirone. It's not being used for anxiety in this case. She makes a point to tell the patient, "I'm not treating anxiety with this," but buspirone has been tested in this condition and it can actually provide relaxation and help with the visceral hypersensitivity and also help the stomach accommodate food.
For epigastric pain syndrome with epigastric burning, we have the tricyclic antidepressants (TCAs), which many of us are familiar prescribing. She prefers the newer-generation TCAs, amitriptyline and imipramine. Start low and go slow.
Does everybody with functional dyspepsia need esophagogastroduodenoscopy (EGD)?
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